SNFData - 355041 - 06/2014 - Worksheet D Part I

LUTHERAN HOME OF THE GOOD SHEPHERD
NEW ROCKFORD, ND 58356

Medicare Provider Number: 355041

Cost report status: Settled With Audit

[Record Code 1084098 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST		Provider CCN: 355041		PERIOD: FROM 07/01/2013 TO 06/30/2014		WORKSHEET D PART I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center Description		Ratio of Cost to Charges (from Wkst. C, col. 3)	Health Care Program Charges		Healthcare Program Cost
		Ratio of Cost to Charges (from Wkst. C, col. 3)	Part A	Part B	Part A ( col. 1 x col. 2 )	Part B ( col. 1 x col. 3 )
		1	2	3	4	5
ANCILLARY SERVICE COST CENTERS
40	Radiology						40
41	Laboratory						41
42	Intravenous Therapy						42
43	Oxygen (Inhalation) Therapy						43
44	Physical Therapy	###	###		###		44
45	Occupational Therapy						45
46	Speech Pathology						46
47	Electrocardiology						47
48	Medical Supplies Charged to Patients						48
49	Drugs Charged to Patients	###	###		###		49
50	Dental Care - Title XIX only						50
51	Support Surfaces						51
52	Other Ancillary Service Cost						52
OUTPATIENT COST CENTERS
60	Clinic						60
61	Rural Health Clinic (RHC)						61
62	FQHC						62
63	Other Outpatient Service Cost						63
71	Ambulance (2)						71
100	Total (sum of lines 40 - 71)		###		###		100
(1) For titles V and XIX use columns 1, 2 and 4 only. (2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)
08-16						Rev. 7